|Year : 2018 | Volume
| Issue : 2 | Page : 172-174
A case of laparoscopic extraction of a displaced intrauterine contraceptive device
Manoj Mukund Paprikar1, Anurav Yadav2
1 Department of Obstetrics and Gynaecology, INHS Kalyani, Vishakhapatnam, Andhra Pradesh, India
2 Department of Surgery, Base Hospital, Guwahati, Assam, India
|Date of Submission||29-Aug-2018|
|Date of Acceptance||09-Nov-2018|
|Date of Web Publication||10-Jan-2019|
Lt Col Manoj Mukund Paprikar
Department of Obstetrics and Gynaecology, INHS Kalyani, P.O. Gandhigram, Vishakhapatanam - 530 005, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Intrauterine Contraceptive Devices (IUCD) are commonly used in India as a means of contraception. It is a safe, effective and economical method. The complications include menorrhagia, expulsion, migration and ectopic pregnancy. Displaced IUCDs after uterine perforation can be located at many sites like pelvis, adnexa, bowel, bladder, abdominal cavity. They can have an unusual presentation. They require surgical removal preferably laparoscopically, although conversion to open surgery especially in abdominal cavity is quiet common. Here we present a case which had an unusual presentation and was found close to umbilicus embedded in omentum. The IUCD was successfully extracted out laparoscopically.
Keywords: Displaced, intrauterine contraceptive device, laparoscopy, uterine perforation
|How to cite this article:|
Paprikar MM, Yadav A. A case of laparoscopic extraction of a displaced intrauterine contraceptive device. J Mar Med Soc 2018;20:172-4
| Introduction|| |
Intrauterine contraceptive device (IUCD) is the most common method of contraception used by women. It is safe, effective (birth control), and cost-effective. Complications of IUCD include menorrhagia, expulsion, migration, and ectopic pregnancy. Uterine perforation has been reported in 0.1% of cases. Kassab et al. in a review spanning 18 years noted 165 reported cases of IUCD migration. The IUCDs were located in the omentum, rectosigmoid, peritoneum, bladder, appendix, small bowel, adnexa, and iliac vein. Despite most cases being asymptomatic, the current guidance is that all misplaced IUCDs should be surgically removed. Here, we describe a case wherein there was a confusion in the diagnosis due to an unusual presentation. The case was successfully tackled laparoscopically with the IUCD lying in a very unusual location. Only three such cases have been reported in India by a review series by Mosley et al.
| Case Report|| |
A 26-year-old patient was admitted with the chief complaints of umbilical discharge for the past 3 months. There was local reddening of the surrounding area from 15 days. There was no history of pain or fever during the same period. She had taken a course of antibiotics. She did not respond to it. Then, she underwent ultrasonography, which was suggestive of an infected urachal cyst with a fistulous opening in the umbilicus. Then, she was again treated with antibiotics, locally as well as systemically. She was provisionally diagnosed to be a case of either an infected umbilical granuloma or an infected urachal cyst.
As there was no response to the treatment, a computed tomography (CT) scan was performed. The CT scan clearly showed an IUCD, which was lying in the peritoneal cavity near the umbilicus. It was surrounded by fatty tissue, which was reaching up to the umbilicus. The patient gave a history of IUCD insertion 1 year back after the delivery of the second child. It was then decided to offer the patient surgical exploration. The patient finally approached our institute with this diagnosis.
It was decided that the patient be taken up for diagnostic laparoscopy and proceed further as per the findings. Since there were features suggestive of adhesions in the periumbilical region, three ports were created – two 10 mm ports, one umbilical, and the other on the left lateral side. A third 5 mm port was created on the left side. The uterine perforation was identified in the fundal region [Figure 1]. No adhesions were seen in the pelvic region near the uterus. There were omental adhesions extending up to the umbilicus [Figure 2]. The IUCD was not visible directly. The adhesions were dissected out using Harmonic scalpel. It revealed the IUCD, which was embedded in the omental mass [Figure 3] and [Figure 4]. The IUCD was freed and extracted out of the port. After ensuring haemostasis, the ports were closed [Figure 5].
|Figure 2: Intrauterine contraceptive device embedded in the omentum adherent to the umbilicus|
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|Figure 4: Intrauterine contraceptive device being extracted out of the port|
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|Figure 5: Intrauterine contraceptive device extracted out of the abdomen|
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Postoperatively, the patient had a smooth recovery. The sutures were removed on the 7th day, and there was no discharge through the wound site.
| Discussion|| |
Minimally invasive techniques, such as hysteroscopy and advanced laparoscopy, are ideally suited for the diagnosis and surgical management of the displaced IUCD. These techniques allow for the localization and retrieval of these devices in most cases.
A review by Moseley et al. revealed that the majority (93.0%) of reported cases were attempted laparoscopically; however, 22.5% of these were converted to open procedures. The overall rate of open surgery was found to vary according to the site of the misplaced IUCD. The patients with an IUCD that was related to both abdominal and pelvic organs had the highest rate of open surgery at 57.1%, compared with a rate of just 12.9% in those related to only pelvic organs and 40.0% in those related to only abdominal organs. These rates are likely to reflect the complexity of the surgery required to remove the IUCDs because the majority of those located in the pelvis was “free” and not fixed to the pelvic organs, it is not surprising that the rate of conversion was lowest among these cases.
This case was rare as there were no case reports of the IUCD migrating to the level of the umbilicus and lying buried inside the omentum. It also created a diagnostic difficulty due to a confusing presentation. After diagnosing it, it was successfully extracted out laparoscopically without the need to convert to open surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mosley FR, Shahi N, Kurer MA. Elective surgical removal of migrated intrauterine contraceptive devices from within the peritoneal cavity: A comparison between open and laparoscopic removal. JSLS 2012;16:236-41.
Nagel TC. Intrauterine contraceptive devices. Complications associated with their use. Postgrad Med 1983;73:155-64.
World Health Organization. Mechanism of Action, Safety and Efficacy of Intrauterine Devices: Report of a WHO Scientific Group. Vishakhapatnam: World Health Organization; 1987.
Kassab B, Audra P. The migrating intrauterine device. Case report and review of the literature. Contracept Fertil Sex 1999;27:696-700.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]